Gum disease, a very common ailment affecting nearly half of Americans over 30 and over 70% of those over 65, is a condition where chronic inflammation of the gums/gingival tissue can lead to discomfort and potentially to loss of teeth. Gum disease, called gingivitis (or for deeper penetration of the process—periodontitis), is usually caused by a combination of factors, including: (a) tissue qualities in the patient's mouth (usually at least partially genetically determined); (b) patient hygiene and home/professional care (i.e., brushing, flossing and dentist visits); and/or (c) various types of bacterial growth in the mouth (which can often be affected or controlled to a significant degree with proper oral hygiene).
Two salient factors that can contribute significantly to the development of periodontal disease are plaque and tartar. Plaque, a sticky bacterial film that can accumulate on the sides of teeth, not only can lead to tooth decay by increased local acid concentration, but can also irritate and cause inflammation of the gums/gingival tissue. While in most cases plaque can be removed through daily brushing, flossing, and oral rinsing, in some cases the plaque, in combination with minerals in the saliva, can form a hard, crusty build up at the base of the tooth known as tartar. This tartar, removal of which often requires professional intervention, will typically continue to calcify and irritate the gingival tissue, worsening the local inflammation. As a result of this inflammatory process, the gums can partially separate from the base of the tooth, creating pockets next to the teeth that not only expose the root of the tooth, but also create additional places for bacteria to reside. In many cases, these pockets can become too deep to be adequately cleaned by home care methods, including dental floss, ultrasonic toothbrushes, or pulse lavage irrigation.
The existence of periodontal “deep pockets” can cause a variety of symptoms, including bad breath, patient discomfort, temperature sensitivity, gum recession (i.e., longer appearing teeth), and bleeding gums, but the most insidious effects can include loss of supporting bone structure which can lead to loss of teeth. This loss of bone structure occurs as part of the reaction to chronic inflammation that occurs at the base of the pockets. Since the depth of the pocket cannot typically be adequately cleaned by patients themselves, this region remains chronically colonized with multiple forms of bacteria in a situation that clinically is essentially a chronic low grade infection. The mechanism of the destruction of bone with potential for loss of teeth involves the effects of the immune system as part of a cascade of cellular responses to this chronic inflammatory state. Cells involved in the inflammatory response cause, among other effects, release of cytokines (secretions from cells of the immune system that affect other cells) as well as other mediators, but the net effect is that both supporting bone and the periodontal ligaments (which attach teeth to bone) slowly resorb/disappear. This process continues until the source of the inflammation/infection, the bacterial plaque and any accumulated tartar that resides on the teeth, is cleaned. Given that there is lower likelihood of this chronic inflammation occurring when the bacteria have fewer anatomic locations to become sequestered, the risk of bone and tooth loss would be significantly diminished by a treatment that could decrease or limit the depth of the periodontal pocket.
Current options available to dental professionals for prophylaxis (disease prevention) and for treatment of periodontitis include (a) home care and regular dental hygiene and flossing by the patient; (b) periodic deep cleaning in a dentist's office, including scaling and root planing; (c) the application of medications to the patient's mouth, including antibiotic rinses, gels, and other delivery systems including microspheres; (d) the use of custom dental appliances impregnated with antibiotics proximate to the inflamed locations; and/or (e) the employment of various oral surgical procedures, including flap surgery. Flap surgery involves lifting the gums to remove tartar and/or deposits and allowing the surgeon direct access to the base of the tooth, and then suturing the gums back to result in significantly more shallow (less deep) periodontal pockets. In many instances this flap surgery option can result in more gum recession (i.e., there is less gum tissue left, so teeth appear longer) or the need for bone or tissue grafting (i.e., taking bone or gum tissue from elsewhere to pack into a small area to promote tissue regeneration, to allow connective tissue to re-grow).
Despite the best intentions of the dental health professionals, and good home care efforts by the patient, traditional treatments for periodontitis can slow but often not halt disease progression. Even with brushing and flossing, and even with mechanical assistance from appliances such as the ultrasound toothbrush (e.g., SONICARE) and pulse lavage (e.g., WATERPIK) devices, the depths of the pockets, especially when they get to be greater than 4-6 mm, cannot typically be cleaned thoroughly by the patient, and professional cleaning is often required. In most instances, this type of deep cleaning involves either some sort of discomfort, or administration of local anesthesia, and is not without significant cost.
Aside from the anatomical challenges of cleaning the depths of the periodontal pockets, another issue is that the chronic colonization of the pockets involves multiple forms of bacteria, and even a professional cleaning is often temporary at best. Even if a dental professional were able to get to access the bottom of the pocket and scrape it clean, that area will typically be re-colonized with bacteria almost immediately. Moreover, attempts to decrease the bacterial load in the pockets by locally applying antibiotics with dental appliances have been heretofore unsuccessful, with numerous studies showing that such medication applications do not typically reach the source of periodontal infections at the base of the tooth.
In cases of periodontal pocket formation that require surgical treatment, additional challenges exist. Aside from the patient discomfort and expense, even with flap surgery, since the mouth is not made sterile, there are persistent bacteria at the base of the flap at the time of surgery. Moreover, the gingival flaps are often repaired with sutures, which are themselves foreign bodies that cause a component of tissue reaction/inflammation, and the swelling component of the inflammatory reaction prevents egress/outflow of tissue fluids, creating further areas where bacteria can reside.